Provider Demographics
NPI:1770175671
Name:EMILIA C BAZAN-GROW
Entity type:Organization
Organization Name:EMILIA C BAZAN-GROW
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:EMILIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BAZAN-GROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-750-4937
Mailing Address - Street 1:13235 SW GLENHAVEN ST
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-0958
Mailing Address - Country:US
Mailing Address - Phone:503-750-4937
Mailing Address - Fax:503-746-7445
Practice Address - Street 1:13235 SW GLENHAVEN ST
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-0958
Practice Address - Country:US
Practice Address - Phone:503-750-4937
Practice Address - Fax:503-746-7445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-11
Last Update Date:2022-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty